The Ayushman Bharat PM-JAY is a national public health insurance scheme offered by the Indian government. However, unlike a general health insurance policy, it does not cover everything. Let us take a look.
General Misconceptions About The Ayushman Bharat Yojana
Ayushman Bharat Yojana Covers All Hospital Expenses Up To Rs 5 lakh
While PM-JAY is very inclusive, there are exclusions. Outpatient consultations, cosmetic procedures, fertility treatment, routine dental treatment, and vaccinations are generally not covered. “Coverage is also on pre-fixed package rates determined by the government. If a particular treatment package costs Rs 1 lakh under the scheme, but the hospital charges Rs 2 lakh, only the pre-fixed amount is reimbursed—irrespective of the total Rs 5 lakh sum insured,” says Pankaj Nawani, CEO, CarePal Secure.
The Ayushman Bharat Yojana Insures All The Citizens Of India?
PM-JAY is not for all Indian citizens. “The scheme is for poor families, identified on the Socio-Economic Caste Census (SECC) 2011 for rural and urban areas. It also covers citizens above 70 years of age. The eligibility is not for all, so the people need to verify the PM-JAY beneficiary list,” says Nawani.
You Have To Pay In Advance And Get Reimbursed Subsequently Under The Ayushman Bharat Yojana
No payment is required for this scheme. PM-JAY has a paperless and cashless system. After hospitalization at a registered hospital and verification completed through an e-card, treatment cost is directly handled between the hospital and the program.
Ayushman Bharat Yojana Operates Only At Government Health Centers
PM-JAY is adopted by the government as well as empanelled private hospitals throughout India. Some of the top-ranked private hospitals are covered under the scheme.
Ayushman Bharat Yojana Scheme Is Only For Individuals, Not Families
“PM-JAY insures families, not individuals. The scheme pays a maximum of Rs 5 lakh per family per annum for secondary and tertiary care hospitalization,” says Nawani.
The Ayushman Bharat Yojana Covers Only Complex Surgery Procedures
The program offers more than 1,500 treatment packages, such as interventions for cardiovascular disease, cancer, orthopaedic surgery, and hospitalization conditions.
Once Admitted Through Ayushman Bharat Yojana, You Can Undergo Any Treatment
In practice, treatment must form part of the National Health Benefit Package. Some operations also require hospitals to get pre-authorization.
Exclusions Under The Policy
Exclusions are as per standard hospitalisation insurance — cosmetic treatment/procedures, fertility treatment, OPD, dental treatment, treatment for drug abuse/self-inflicted injury, unproven therapies/treatments, and diagnostic procedures taken individually with doctor’s recommendation. “Mental illness is an exclusion, something normal hospitalisation insurance too does not cover but is mandated by the regulator to cover. They are still grappling with this issue, as most mental treatments do not meet the basic requirement - in-house hospitalisation,” says R Balasundaram, secretary general, IBAI.
However, Balasundaram states that under common hospitalisation policies, pre-existing conditions/diseases are not excluded under Ayushman Bharat. Also, there is no waiting period for specific treatments.
Exclusions under any insurance scheme, including government-run ones like Ayushman Bharat, are necessary in order to gain control over costs. “As desirable as it is that all medical costs are covered, uncontrolled access would lead to excessive costs, making the scheme financially unsustainable for the government,” says Nawani.
